For years people undergoing cancer treatment described
their minds as being in a fog — unable to concentrate
and remember details important to their everyday lives.
Doctors and researchers knew something was wrong, but they
couldn’t put their fingers on what it was.

A growing body of research shows that what those people
were experiencing is called cognitive impairment — the
loss of the ability to remember certain things, learn new
skills and complete certain tasks. The cause of cognitive
impairment during cancer treatment still isn’t clear, nor
is it clear how often it happens or what may trigger it.
Doctors aren’t sure what they can do about it.

But that doesn’t mean there isn’t any hope. Recognize
cognitive impairment and its association with cancer
treatment, and talk to your doctor about your symptoms or
concerns. Taking small steps can help you cope with
changes in your memory during treatment.

You may have heard the terms
chemobrain and chemofog.
These terms refer to cognitive changes during and after
cancer diagnosis and treatment. Women with breast cancer
who underwent adjuvant chemotherapy were the first group
to bring these symptoms to light, as more started
mentioning their symptoms to their doctors. It isn’t clear
whether chemotherapy, or other factors such as stress and
hormonal fluctuations, cause the changes in memory and
thinking. What is clear is that some people with cancer do
notice increased difficulties with certain mental tasks
after cancer treatment.

In general, researchers have found that chemotherapy
can affect your cognitive abilities in the following
manners:

Word finding.
You might find yourself reaching for the right word in
conversation.

Memory. You
might experience short-term memory lapses, such as not
remembering where you put your keys or what you were
supposed to buy at the store.

Multitasking.
Many jobs require you to manage multiple tasks during
the day. Multitasking is important at work as well as
at home — for example, talking with your kids and
making dinner at the same time. Chemotherapy may
affect how well you’re able to perform multiple tasks
at once.

Learning. It
might take longer to learn new things. For example,
you might find you need to read paragraphs over a few
times for the message to set in.

Processing speed.
It might take you longer to do tasks that were once
quick and easy for you.

About 20 percent to 30 percent of people undergoing
cancer treatment will experience cognitive impairment,
though some studies report that at least half the
participants had memory problems. Signs and symptoms of
these memory changes last for at least a year or two after
your treatment. The changes can continue for several years
or they can go away sooner.

Changes in memory during and after treatment may be
very subtle. You might notice changes during your everyday
tasks and as you start working again after treatment. The
memory changes are often so subtle, in fact, that
researchers find that people who report having memory
difficulties tend to score in the normal ranges on tests
of their cognitive ability. That makes it more difficult
to understand, diagnose and treat the memory changes.

What causes the
memory changes?

Doctors don’t know what causes the cognitive changes
associated with chemotherapy. It was previously thought
that chemotherapy drugs didn’t enter your brain, but were
rejected by the blood-brain barrier, which separates
things that should be in your brain from those that
shouldn’t. But some researchers now suspect some
chemotherapy drugs may be able to slip past the
blood-brain barrier. This could potentially affect your
brain and your memory.

It isn’t clear which chemotherapy drugs are more likely
to cause memory changes or if higher doses pose a bigger
risk than do smaller ones. And it isn’t possible to
predict who’s more likely to have cognitive impairment
after chemotherapy.

A number of factors can cause temporary memory problems
in people undergoing chemotherapy — making it difficult
to decipher the so-called chemobrain from the normal
stresses of treatment. Temporary memory problems can, for
the most part, be treated. Causes include:

Low blood counts.
If your blood counts are low, you might feel tired,
making it difficult to concentrate.

Stress. Being
diagnosed with cancer and starting treatment is
stressful. Stress also makes concentrating difficult.

Medication to treat side
effects. Certain medications for treating
side effects such as nausea and vomiting may cause
drowsiness. When you’re tired, it may take longer to
complete tasks.

Lingering depression.
Depression is common in people with cancer. If your
depression continues after your treatment, you might
find it difficult to pay attention.

Lingering fatigue.
Fatigue is a side effect of several types of cancer
treatment, including chemotherapy. Your fatigue might
end when your cancer treatment ends, though it also
can continue after treatment.

Hormonal changes.
Many cancer treatments may alter the normal hormonal
balance in your body, causing cognitive changes.
Hormonal changes are a side effect of some treatments
and, with other treatments, are the intended way to
treat your cancer.

Talk to your doctor about your memory problems. If your
symptoms are caused by medications or stress, your doctor
can treat those symptoms and help get your mind back on
track.

If you have impaired memory, your doctor may first try
to rule out any other causes of memory problems, such as
stress and depression. Currently no medications exist to
treat cognitive impairment associated with cancer and its
treatment. Researchers are investigating whether
medications for such disorders as depression,
attention-deficit hyperactivity disorder (ADHD) and
dementia could prove effective.

You can help yourself cope with the changes in your
memory by taking a few simple steps. You might want to:

Exercise your body.
Aerobic exercise helps your mood and can make you feel
more alert. Both can help you when it comes to
concentrating.

Exercise your mind.
Give your mind a workout by learning a new skill, such
as a new language. Take a class or participate in a
book club.

Track your memory
problems. Keep a detailed diary of your
memory problems throughout your day. Carry your diary
with you and take quick notes on what medications you
take and when. Note the time of day your memory
problems occur and the situation.

Target specific
problems. Use your daily diary to determine
what influences your memory problems. If they tend to
crop up in the early afternoon, you can prepare
yourself by not scheduling meetings or deadlines at
that time of day.

Take notes.
Make a list of everything you need to accomplish today
and use that as a guide. Take detailed notes of things
you need to remember.

Start a routine.
Put your keys or other commonly misplaced objects in
the same place every time you set them down. Try to
keep the same schedule every day.

Talk about your
problems. Be open with your friends and
family about what you’re experiencing. Let them know
your mind is moving a little slower these days and
explain how they can help you. This can make you more
relaxed and make it easier for you to think and
process information.

Find the coping method that’s best for you and stick to
it. Talk to your doctor about your concerns. He or she
might have some other suggestions.

Chemotherapy isn’t the only cancer treatment that may
cause memory and thinking problems. Other treatments that
might affect your brain include:

Hormone
therapy.
It isn’t clear whether women undergoing hormone
therapy that alters the amount of estrogen in their
bodies experience memory problems. Some studies link
memory to the amount of estrogen in the brain. Other
studies haven’t found this link.

Radiation therapy.
Radiation to your brain can impair your memory and
your motor function, as well as your ability to learn
new things and to multitask. Older adults and people
receiving high doses of radiation are at a greater
risk of memory problems. If you receive both
chemotherapy and brain radiation, your risk is also
higher.

As research continues doctors will be able to better
understand which cancer treatments cause cognitive
impairment and what they can do to limit their side
effects.

Take note of any
memory problems

If you’re currently undergoing cancer treatment or
you’ve already been through treatment, take note of any
problems you have remembering certain things or
concentrating during certain tasks. Talk to your doctor
about your signs and symptoms.

If you’ve yet to start your treatment, talk to your
doctor about the risks of treatment, including cognitive
impairment. Understanding your risks can help you make
more informed decisions about your treatment.

Chemobrain – Real Or Fiction?

Rachael Myers Lowe, cancerpage.com

June
21, 2004

Fuzzy thinking, difficulty learning new things, trouble
recalling words or remembering details and focusing attention have been
associated with chemotherapy
in previous studies of breast cancer
patients. A new study of breast cancer patients by researchers at the M.D.
Anderson Cancer Center in Houston questions the validity of the earlier
research and concludes earlier reports “may have overestimated the true incidence
of decreases in cognitive functioning secondary to chemotherapy.”

Writing
in the August 1 issue of Cancer, a publication of the American Cancer
Society, Christina A. Meyers, Ph.D., and colleagues report that 35% of the
women in their study had mental impairment before they began systemic
chemotherapy. Taking a measure of cognitive function before adjuvant
chemotherapy was administered was not done in the previous studies.

“Given
the current documentation of objective cognitive impairment before adjuvant
systemic therapy, a large portion of patients in previously published
reports who performed at levels below what was expected when they were
assessed after chemotherapy may well have performed at that same level
before chemotherapy,” the authors write.

Is
chemobrain is a fiction?

“Absolutely
not!” Meyers told cancerpage.com.

Meyers
says she has another study recently published that tested women before
they had treatment, while they were on treatment, and a year after
treatment had stopped.

“Sixty
percent of those folks declined on chemotherapy so chemo brain is for real
It’s just that it’s not a simple as that, not that it was ever simple.
There’s also cancer related aspects to take into consideration and then
there’s the aspects of the person themselves, susceptibilities or
vulnerabilities in certain people to develop these symptoms,” she said.

Perhaps
chemobrain is a bad name. The issue of cognitive impairment in cancer
patients may be caused by many factors: a patient’s genetic
makeup, nutritional factors, immune system, hormonal history, reduced
“cognitive reserve” may increase cognitive impairment. The cancer
itself may also contribute to development of cognitive dysfunction.

In
the study detailed in Cancer, Meyers and colleagues studied the mental
functioning of 84 women who had been diagnosed with breast cancer but had
no evidence of metastatic
disease. They all were older than 18 years of age (on average nearly
51 years old), had completed more than 8 years of formal education (14
years was the average), and spoke fluent English. None of the patients had
a previous history of depression, earlier cancer, or were taking any
substances that would affect the central nervous system. All patients had
either undergone surgery or a needle biopsy
before the mental function tests were given. Some of the patients had used
hormone replacements therapy (HRT); some had undergone adjuvant
radiotherapy.

They
were all given a battery of tests, before adjuvant chemotherapy began and
after, to measure attention, memory, language, executive function, visual
and motor skills, depression, and anxiety.

Going
into their treatment, 35% of the women registered at least one measure of
cognitive impairment; 26% reported some symptoms of anxiety or depression.
Women who reported anxiety or depression were much more likely to
experience impaired cognition of some degree pre-chemotherapy.

Compared
to what’s considered normal, pre-treatment women with breast cancer
experienced the greatest impairment to verbal learning and verbal memory.
Other impairments were less pronounced.

The
researchers said some trends, while not statistically significant, were
worth further investigation: patients who underwent more invasive surgery
(lumpectomy versus mastectomy), patients who were postmenopausal, and
patients who had not previously used any HRT
appeared to be at greatest risk of pre-treatment cognitive impairment.

The
bottom line is more research needs to be done that measures cognition
before and after treatment. The authors say doctors should continue to
counsel their patients on cognitive functioning and refer them to
specialists if they or their families report changes in the patient’s
ability to think.

Is
mental impairment common in other cancers? Meyers says she has found it in
newly diagnosed but untreated small-cell lung cancer patients and leukemia
patients.

SOURCE:

Cancer
August 1, 2004. Published online June 21, 2004.

cancerpage
telephone interview with Christina Meyers, 6-21-04

ChemoBrain/Cognitive Dysfunction

Tara
Parker-Pope, The Wall Street Journal, April 6, 2004

For
years chemotherapy patients who complained of memory problems — or
so-called “chemo brain” — were told it was all in their head.
But new research shows that chemo brain is real.

While
cognitive complaints following chemotherapy have often been written off to
depression, anxiety and even menopause, doctors now know that chemotherapy
can trigger real — and sometimes lasting — changes in a patient’s brain.
Last week, researchers from University of California-Los Angeles presented
imaging studies at a scientific meeting in Orlando, Fla., showing marked
differences in the brains of breast-cancer patients who had undergone
chemotherapy compared to patients who had undergone surgery alone. Studies
are just beginning on whether certain drugs or cognitive therapy can help
prevent or offset that side effect. Some patients are given the stimulant
Ritalin, which can help improve concentration.

Not
every patient develops cognitive problems after chemotherapy, but enough
people do that more and more doctors are beginning to warn patients about
the potential side effect, says Eric Winer, director for breast oncology
at the Dana-Farber Cancer Institute in Boston. Most of the problems
typically relate to focus, fast thinking, organization skills and an
inability to multitask.

The
problem has been most studied in breast-cancer patients, in part because
many of those patients are relatively young and highly educated and have
high survival rates. That makes cognitive declines more noticeable
compared with declines in older or retired patients. But cognitive
problems have also been noted in other cancers, including lymphoma and
lung cancer.

Much
more research is needed to say conclusively how widespread the problem is.
Studies of breast-cancer patients show that nearly two-thirds of women
treated with chemo develop some level of cognitive problems, though most
recover on their own in the weeks or months after treatment stops. Still,
as many as 20 percent to 25 percent of patients may develop lasting
problems, says Tim A. Ahles, program director of the center of
psycho-oncology research at Dartmouth Medical School, which has led much
of the research on the subject.

For
patients, the simple acknowledgment that their complaints are real has
been a long time coming. Houston resident Janis Shea, a nurse and former
college professor, says that after undergoing chemotherapy for breast
cancer, she began having trouble finding words and balancing her
checkbook. Even her sense of humor was off. She recalls a friend telling a
joke about shoes made from bananas. The punch line — “slippers”
— was lost on her.

“Everybody
was laughing, but I just didn’t get it,” she says. “I used to
teach and lecture to 200 people and I was having trouble putting sentences
together.”

Ms.
Shea attended a support group and discovered other women were hesitant to
talk about the problems out of fear it would jeopardize their careers or
because their doctors didn’t think the problem was real. Ms. Shea’s
complaints prompted her husband, a physician at the University of Texas
M.D. Anderson Cancer Center, to discuss the issue with colleagues, who
began research into the problem as a result.

But
studying the ailment is tough. Some of the symptoms, such as short-term
memory problems and loss of verbal fluency, can also happen during
menopause, when estrogen production begins to plunge. Many breast-cancer
patients are in the midst of menopause or thrown into it by the treatment.
Memory problems also are associated with depression and fatigue, both
common problems among cancer patients.

However,
brain images show that in some people chemotherapy can trigger distinct
changes. At UCLA, researchers studied the brains of breast-cancer patients
who complained about cognitive problems after chemotherapy — comparing
them to women with breast cancer who didn’t receive chemo. In the women
who had undergone chemo, the images showed differences in metabolic
activity in the parts of the brain involved in language; some parts of the
brains of chemo-treated woman looked 25 years older than they were.
Knowing that real changes have taken place in the brain has actually
helped many women cope, says Dan Silverman, head of neuronuclear imaging
at UCLA. “They say, ‘Now I know I’m not crazy,” he says.

In
studies at M.D. Anderson, patients were given neuropsychological
assessments both before and after chemo, and about 60 percent showed
significant cognitive decline after treatment. It’s important to note that
even though the problems are frustrating, they typically are subtle and
manageable, says Christina Meyers, professor of neuropsychology at M.D.
Anderson, where several studies are underway.

Dr.
Meyers says the neuropsychological tests can reassure patients by ruling
out Alzheimer’s, and help them better understand whether the problem is
related to chemo, depression or other issues.

Researchers
at Dartmouth University are studying “cognitive rehabilitation”
for chemo patients, focusing on compensation strategies, such as writing
detailed notes or using a hand-held organizer, as well as relaxation
techniques, because cognitive problems increase with stress. At M.D.
Anderson, some patients take Ritalin to help them focus, but researchers
also are studying whether giving the anemia drug Procrit before chemo can
prevent cognitive damage.

For
patients who need chemo, the problems aren’t significant enough to turn
down treatment. But doctors say patients who are borderline candidates may
want to factor the potential cognitive side effects when deciding whether
to undergo chemotherapy.

Note

If you experience symptoms of chemobrain, I strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information contained in this website is meant to be helpful and educational, but is not a substitute for medical advice.

If you feel your medical team is not informed or supportive about chemobrain I urge you to refer them to this web site or seek out a provider among those listed who are actively engaged in the research and writing on this complex matter.